- A labourer in Santos, a port in Brazil, suddenly gets a high fever. His eyes are bloodshot, but there is no pus. He has a terrible headache and pronounced muscle pains. He is coughing. The diagnosis of influenza is made. A few days later his urine is dark and hepatitis is suspected. Another few days later there is still severe headache and neck stiffness occurs. Meningitis is considered. Lumbar puncture shows an increased lymphocyte count, but no organisms. The man remarks that his stools are black and smell bad. Is the fact that 10 days ago he fell into a sewer relevant? Is the detail of black stools relevant? If it is wished to rule out the initial diagnosis of fulminant hepatitis A, and serology will take too long, what could liver tests contribute?
- A cyclone has led to heavy rains and floods in Myanmar (Burma). You find a man with a dry cough, fever, jaundice and various haemorrhages (nose, gums, melena). Your colleague thinks this is a case of yellow fever. What do you think? What about the possibility of scrub typhus?
- Ethiopia. A large family of refugees arrives in a camp. One man has had a high fever, headache and muscle pain for three days. There is pronounced cough and dyspnoea. His eyes are bloodshot. This morning the fever has subsided but his general condition has worsened. He is bleeding from nose and mouth. You notice red spots on his arms, torso and legs which do not blanch upon pressure. The liver and spleen are swollen. You are told that the previous week the brother of this patient died with identical symptoms. His wife has also had a similar illness, but has survived. She has lost her unborn child, however, and now has paralysis of the left side of her face. Do you expect anything from a thick smear? What do you do? To avoid further cases, someone suggests finding and destroying all rats and rodents in the camp. What do you think?
- Eritrea. A 16-year-old girl has had an ulcer on her right leg for two months. The edges are slightly elevated. The lesion is not painful, but is very gradually widening. Your colleague thinks it is a tropical ulcer. What do you think? Do you begin treatment with penicillin?
- A white woman is visiting a number of remote villages in Senegal as a tourist. She is sleeping under primitive conditions "like the local people". A little while later she is febrile and there is pronounced malaise. After a few days she feels better. Two weeks later she develops the same symptoms. Malaria is suspected, but no trophozoites are found in a thick smear. It is reported that the quality of the smear and the thick smear are not so good, because some microscopic threads of cotton wool seem to have adhered to the slide. What do you think? Possible treatment?
- Cuba. A man falls overboard at sea from a sailing boat when he is 5 km out from the coast. He is rescued and resuscitated. If he develops a cough or fever, should leptospirosis be included in the differential diagnosis?
- Sumatra. You are visiting a village in swampy surroundings. You are told that there has never been a case of leptospirosis in the whole district. The argument is made that leptospires have never been found in blood or urine and that they therefore no longer need to be tested for. What do you say?
- Name three different spirochaetes which are neurotropic.
- Timor. Three children were recently admitted with leptospirosis. They waded recently through a local lake. A Swiss fish biologist is doing research and has to go into the water daily for the next 4 weeks. Which advice on prevention do you give him?
- Why do you think that historically leptospires were discovered during a yellow fever epidemic?
- Thailand. At the Cambodian border, a professional photographer is planning to take pictures of water beetles in their natural biotope every day over the next 4 weeks. Someone advises him to take one tablet of vibramycin daily. Any idea why?
- Nicaragua. In 1995 in the region of Achuapa, after excessive rainfall with floods there was an epidemic of an acute febrile illness, accompanied by headache, muscle pain, dyspnoea and pulmonary haemorrhages. In the end this proved to be a new variant of leptospirosis. What diseases should you include in the initial differential diagnosis: dengue, yellow fever, arenaviruses, filoviruses, rickettsioses, hantaviruses?
